Healthcare Provider Details

I. General information

NPI: 1730103045
Provider Name (Legal Business Name): JAY H. BLACKBURN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W. MERCHANT STREET
NEW BUFFALO MI
49117-1813
US

IV. Provider business mailing address

105 W. MERCHANT STREET
NEW BUFFALO MI
49117-1813
US

V. Phone/Fax

Practice location:
  • Phone: 269-469-3140
  • Fax: 269-469-6182
Mailing address:
  • Phone: 269-469-3140
  • Fax: 269-469-6182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13579
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: